Saturday, January 31, 2009

Many of you are probably familiar with the recent sale of Wellsphere, a health blog aggregator, to HealthCentral Network this past week. This sale has thrown the medical blogosphere into protest mode, though I think it is undeserved.

Dr Val Jones reports the saga very completely on her new health blog, Better Health (also see post from Hippocrates). Last year, medical bloggers were inundated by doting emails from a Dr. Geoff Rutledge. Mine began like this:

Hi Drs "My three shrinks". ,

I was on a search for the best medical blogs, when I found your Shrink Wrap blog at http://psychiatrist-blog.blogspot.com/. I think your blog is great. Dinah's post on True Emotions struck a chord (My emotions aren't Italian, either), and your iphone edition grand rounds was remarkable. [links added]

I'd like to invite you to participate in the network of medical expert bloggers at Wellsphere, but perhaps I should explain a bit about myself and about Wellsphere as background. ...

Despite the expressed familiarity, note the form letter formatting. Dr Val reports that some 1700 medical bloggers fell for the praise and the proposition that, in return for letting Wellsphere repost your blog content on their site, you will be (1) associated with Wellsphere, which then crowed about more than a million page views per month, and (2) you will receive more traffic from them.

What has happened is that many agreed to the Terms of Service without actually reading them, which did not require you to hand over your first-born, but nearly so:

...When you post your own copyrightable content on the Website or give Wellsphere permission to post your copyrightable content on the Website, you retain ownership of any copyright you claim to your submitted content. However, by posting your content or giving Wellsphere permission to post your content you automatically grant Wellsphere a royalty-free, paid-up, non-exclusive, worldwide, irrevocable, perpetual license to (i) use, make, sell, offer to sell, have made, and further sublicense any such User Materials, and (ii) reproduce, distribute, create derivative works of, publicly perform and publicly display the User Materials in any medium or format, whether now known or later developed…

I think many bloggers saw the potential for more traffic as a boon, but now feel stung because Rutledge and company made some easy money by flipping the effort to HealthCentral, while the bloggers who provided all the content received nothing.

My view: caveat emptor. It was clear that Wellsphere's goal was to build a library of content and then sell access to the content to universities and insurance companies. They stated this in their letter of solicitation ("Stanford University was so impressed that they deployed our service for the entire campus. Our business model involves being paid by employers for our service - you won't see today any ads or commercial services on our free public site."). It was clear that the bloggers who agreed to the deal were being compensated only with the potential for greater traffic. For blogs which accept advertising, this meant more advertising revenue. Dr Rob, for one, said that he received no additional traffic from Wellsphere.

A lot of bloggers saw this for what it was and decided that the juice wasn't worth the squeeze. Check out the 50 or so comments to Dr Val's article to see a mixture of those who told the good doctor to take a hike and those who agreed to the deal. While I understand the feeling of betrayal and deception, there are a lot of people saying "Doh! I made a foolish mistake".

Dr Anonymous had a BlogTalkRadio show about this issue two nights ago. The archive of the live show was mysteriously taken down at 10:02 PM yesterday. His explanation: "This show has been deleted and is no longer available for download. I'm sorry for any inconvenience. I have no further comment at this time." Hmm.

I went through my mail and found the interchange we had with Dr Rutledge last July, which was not marked private or confidential and which was unsolicited. Here was my reply, to which he said "Thanks, but no thanks," I did the same, and that was that (except for eleventy million more praiseful form letters despite my requests to "unsubscribe").

Geoff,

Thank you for your request. I reviewed the site and found it a bit frustrating. For example, I searched on the term "xanax" and got several pages of links which were all the same, except for each being a different city. The relevant links were only at the end of the 5 pages. I also could not locate a Psychiatry section on your site.

While I understand that your business model is not aimed at advertising but rather at contracting with clients for your aggregated content and community, I do not see how that income flows down to your content providers. It would seem that the only benefit to the blogger is more traffic.

If you Google "psychiatry blogs", you will see that we are already the first hit. Our podcast is usually in the top 20 in the Medicine section on iTunes. We have over 8,000 monthly unique visitors for our blog (Shrink Rap) and over 10,000 podcast downloads per month for our psychiatry podcast, so increasing our hits is not so valuable to us as cold, hard cash. While these numbers are not huge, we have a close community with 1/3 of our visitors returning at least monthly.

I think that your model will unfortunately encourage lower-quality bloggers who have lots of ads running throughout their sidebars and posts, as this is the group that would most benefit from increased traffic.

So, we decline your offer as is. However, if you'd like to pay us to use our content, we would consider $1250 monthly. Also, if you are interested in being a sponsor on our My Three Shrinks podcast, we would consider $600 per podcast. This covers the cost of producing the podcast and is not connected to CPM, but allows access to a highly targeted market (mental health consumers and professionals). Either of these agreements would depend on approval from my two co-bloggers.

Best wishes and have a nice day,-Roy

When we first got the form letter, ClinkShrink sent me a message stating, "Almost sounds too good to be true. Whaddya think?". So, the lesson here is an old one. If it sounds too good to be true, then it probably is.

Thursday, January 29, 2009

So I wrote about the 12 ways to drive ME crazy...and it got a few comments. I've nothing better to post about, so I thought I'd address those comments here. My co-bloggers seem to have gone dark with posting. I hope it's okay if I reference the random commenters.

One commenter wrote in an additional idea:13. Spend the treatment session being totally non-compliant and then tell everyone how useless your therapist is.

Fortunately, if my patients are feeling I'm useless, they aren't telling me. Many are non-compliant, and that just goes with the turf of being a shrink. I've been at it too long to take it personally or to be driven crazy by it.

Return of Saturn (what a great blog name!) is worried about returning to care after a few no shows and a few years. Personally, I'm always flattered when people return to treatment. I'm sorry they are feeling badly, but I like that they feel comfortable enough coming back. And No Shows are a pretty common thing, they aren't something that gets held in long term shrink memory. They do generally get charged for, however.

For everyone who commented on Calling Between Sessions: it's only necessary if a shrink specifically asks to be called. No one is waiting on unrequested calls. If a shrink requests a check in, then ends up chasing the patient down repeatedly, well....it gets to be plain inconsiderate. Often, however, we work on the No News Is Good News theory and lost sleep is the exception, not the rule.

Mindful wants to know what personal intrusive questions I get and the worst of them isn't going on the blog. Try This for a post on Questions for the Doctor.

Anonymous wants to know why I like Seroquel better than Xanax and says it's more toxic. I like Seroquel better than Xanax because you can give someone a very low dose to take as an emergency medication (yes, off label, and yes I explain this) and it's not addictive and doesn't cause physical dependency, so they can take it or not take it, while Xanax gets you committed fairly fast. Given all we now know about the metabolic issues with Seroquel and the atypical antipsychotics, I'm a lot more hesitant about giving these medications and it's fairly rare that I use them off label. At this point, this is really an emergency measure for someone feeling pretty desperate or on the verge of hospitalization. And Xanax isn't much of an issue any more because so few shrinks prescribe it on a standing basis that it's been a very long time since a new patient has come to see me already on Xanax.

The same Anon is also concerned that I don't want patients to come off meds when they aren't having side effects, or don't realize that they are until they come off meds.I have to say that I have very few contentious discussions with patients regarding medications. Most people are on medications because they feel better on them, and I'm more often saying it's time to at least consider coming off (many people don't want to risk a relapse and I respect that). I'm with Roy here, who commented that it's really about working with someone and the risk/benefit ratio. My Drive ME crazy list referred to the quite rare case where someone has repeatedly come off meds only to relapse and either the relapse has resulted in hospitalizations, violence, or the patient's misery being so tangible that it felt like my own (and months of very distressed phone calls). Many patients stop their meds: I tell them what I think they should do, what I think the risk of relapse is, and from there, it's not my decision. And I don't stop treating anyone who says they feel better without meds and is willing to risk the unknown. I don't know what to say about side effects: if someone says they aren't having them, I don't argue. And often it's hard to tell the difference between a symptom of illness and a side effect of meds. I do a lot of my thinking out loud and try to share my thought processes with my patients. It's the best I can do.

To Spotsy and Mind Mechanic: thanks for the support.

And to Roy: mostly you got the list of what you do that drives me crazy right. The podcast, however, was your baby, and so it doesn't bother me that you don't post them after we make them. I love your company for it's own sake, so I don't lose sleep over unposted podcasts. ClinkShrink, however, may feel differently. Please please please don' t post what I do that drives you crazy. I don't want to know.

Wednesday, January 28, 2009

The last post was stolen from another blog and was meant as a joke.Here's my personal list, it's not a joke.

1. Don't show up for an appointment. Don't call. Don't answer your cell phone. Don't return my concerned calls.2. Don't show up for an initial appointment where I've blocked out two hours for you. Don't answer your cell phone, never contact me again. Ignore the fact that I made a point of requesting a call if the appointment wasn't going to be kept.3. Insist that Xanax is the only medication that works for you and refuse to try anything else, even once, even if you've never tried it before.4. Insist that a 90 day supply of a very expensive medicine must be written because that's the only way you can afford it through the insurance, and two weeks later announce that it suddenly no longer works.5. Present in a crisis, sit through a session where we develop a plan, then return having done none of it.6. Decide that the medication that was the only thing that worked for you after years of trying to find something, anything, that would work suddenly is something you don't want to take, even though you've been on it, stable, and doing well for a few years with no side effects. When your psychiatrist reminds you how awful your last 7 episodes of illness were, how hard it was to get you better, and that statistically the chances are extremely high that you might get sick again and it might be hard to get you well again, say, "I'm not going to get sick again."7. Attribute your flagrant mania to "real emotion" and insist your psychiatrist can't understand because they aren't Italian/Irish/whatever. (Oh, this doesn't really bother me.)8. Spend the session discussing just how suicidal you're feeling and how badly things are going, and at the end of the session announce that you need to decrease the frequency of the sessions.9. Promise to call between sessions when your shrink is very worried, then don't. Rest assured, shrink will remember you didn't call at 3 AM.10. Ask your shrink very intrusive personal questions. I'll spare you the examples.11. Cancel ten minutes before a session. Tell shrink you suddenly remembered a conflicting appointment that was scheduled a month ago.12. Leave treatment without a word after years of therapy and leave shrink to wonder how you are and how all the details of your life turned out.

I could probably go on for a while. I liked some of the ones people put in the comment section of the last post.

Tuesday, January 27, 2009

In Roy's Top Ten Search Phrases, he notes that How to Drive Your Psychiatrist Crazy is a popular search phrase that gets you to Shrink Rap. Okay, I'll bite. So I pressed the link, and there was a list of what you get when you Google "How To Drive Your Psychiatrist Crazy." I went to the first link and found myself at Clown Ministry, and here were listed 10 ways to drive your shrink nuts. Just what I need. And so...:

Sunday, January 25, 2009

So to summarize my experiment on myself, I manipulated the following variables, all at once, with no control group, and no way of knowing which variable was responsible for any changes I saw.

1) I stopped all caffeine. Well, mostly. After the caffeine withdrawal headache and fatigue, I decided there was no real rationale for this, and I've been drinking half a cup of coffee most mornings. In anticipation of the crowds and a purported 1:5000 person: porta-potty ratio at Obama's Inauguration, I did not have any coffee on that morning. I've had no Diet Coke (yes, this is possible) and my efforts to completely stop chocolate have been unsuccessful. So my caffeine intake has been limited to half a cup of coffee in the morning and episodic chocolate in reasonable (mostly) quantites. No artificial sweeteners.

2) I stopped drinking alcoholic beverages.

3) Since I have trouble falling asleep, but don't have trouble with daytime sleepiness, I wondered if I've simply come to need less sleep and I tried setting my alarm significantly earlier in the mornings. I am not a morning person, and this was awful (it lasted 2 days) but perhaps because it co-incided with my caffeine withdrawal. After that, I started going to bed at least an hour later than I was used to.

4) I increased the amount of exercise I was getting...oh, at least for a while. I also tried to add on some evening exercise to manipulate my body temperature several hours before bedtime-- a few minutes until I got flushed, but not sweaty enough to need a second shower. It was going well until a few days ago when I turned into a human slug. I resume a normal exercise schedule today.

5) Stress-- I started this plan during a time when stress was low and there was a long weekend in there. I've had some stuff going on since, and I spent a night away from home and my usual routine. Sometimes, life is just what it is.

My findings:

It is easier to give up Diet Coke than it is to abstain from Chocolate.

It is easier to give up alcohol than it is to abstain from chocolate.

Decaffeinated tea is as happy an event as regular coffee.

My daytime energy level has not changed with less morning coffee.

One can actually have mild cravings for Diet Coke.

It's easier to go to bed later than it is to get up earlier

It's a pain in the neck to exercise every single day

It is notably cheaper to eat in restaurants when there is no alcohol, soda, or after dinner beverage involved (I don't like decaf coffee).

Oh, and the results: most nights, I'm falling asleep within minutes and sleeping through the night.

Wednesday, January 21, 2009

May I suggest that part of psychotherapy is giving people feedback about themselves they may not want to hear? One of the many reasons why therapy is something different than talking with a friend, or simply 'conversation,' is that the therapist may point out to the patient certain things that in friendly conversation might seem hurtful, unkind, or downright mean. And why? Well, if you don't notice you're doing something, how can you change? Or maybe you don't want to change, but how do you come to make peace with it? Sometimes, it helps to know you're doing distasteful things. Some days I feel like I spend my days insulting people.

The thing is, people don't get offended. The don't meltdown, and there are reasons why this is. There's something about the therapeutic relationship that makes it safe to say things that aren't safe to say elsewhere. Something about the trust the patient holds makes it okay to point out their flaws. Sometimes, it takes a little bit of easing into...and sometimes it takes a little bit of building up at the same time to make it so someone is comfortable hearing something they don't necessarily want to hear. Screaming "You did WHAT?!" doesn't tend to offer room for examination. Saying, "That's interesting, you're the type of person who is usually so in tune to other people's feelings (compliment) that it's funny to hear that you were so mean to Harry (insult)." And of course, sometimes the therapist misjudges and the patient clearly feels badly and then it's time to step back-- hammering someone with something they aren't ready to hear isn't usually all that helpful.

Tuesday, January 20, 2009

If you'll look at the photo above, I'm standing towards the upper left, about 8,000 rows back from the Capitol building, 42 people in from the edge, kind of near the Native American Museum. I have one or the Silver invitations to the ceremonies, which put me up front with the chosen quarter million. I'm standing where I can sort of see a jumbotron, except for the tree in front of it and the people in the tree. It's cold. It's crowded. It's really crowded, and I'm thrilled to be a part of the event.

There's not much to say beyond that. Since commenters have asked about my travel plans:I stayed with a friend in the 'burbs, got dropped at the Metro about 6 AM. I got a seat, but the train quickly filled. I stood in the wrong line for over an hour, but there was no way I could have known that, and no where I could have moved anyway. More lines, cold, and I expected all these things, so it was fine. There was no wind chill factor because all those bodies shielded me from the wind.

The first Metro stop I passed had long lines formed down the street. I tried Union Station and couldn't get near it. I sat for a while on the floor of the lobby to the Postal Museum. The woman next to me was talking on the phone about how she was way in the front, seated and there were marble bathrooms. She saw Usher and Oprah and Denzel. We were at different events, clearly, but both landed on the floor of the museum lobby as inaugural refugees. Oprah and I would hit it off right away, I'm sure of it. All the while, I was getting text messages from the Metro system alerting me to various crowds and shut downs. I texted a friend who works in the District to see if maybe he wanted a visitor. I don't know if he was near me, but what's a few more miles to walk in a crowd on a glorious day? He was inside a building, waiting for the parade, but didn't invite me to join him. I tried the Metro stop in Chinatown, and got through right away. A train pulled up just as I reached the platform. After the first stop, I got a seat, and there were taxis lined up at the station on the other end. I got to my car, drove another hour, and was home by 6.

What an exciting day! I've never seen so many people in my life, anywhere, ever.Congratulations, President Obama!

Monday, January 19, 2009

Okay, once again, I've reviewed our Analytics file for my list of the Top 10 search phrases that people used to find us here at Shrink Rap. These are based solely on those I found funny, interesting, or just bizarre.

I have left the Top 10 search phrases from 2006 and 2007, since just listing these will bring them to the top in the following year. That means I have retired "how to worry your psychiatrist", "freud the meerkat", and -- everyone's favorite -- "sex with fish". So, here goes, my favorite Top 10 from the 39,000-odd search phrases used in 2008:

Sunday, January 18, 2009

You think this post is about psychiatry. Or life in general. Here is going to be the secret, how to unravel it all so it makes sense.

Ha! Tricked you! I just found an article in the New York Times (from 1.15.09) called The Man Who Makes Sense of 'Lost.' It's about Gregg Nations, a man whose job (he gets paid for this!!!) is to keep track of the plot lines for the TV show LOST, a favorite of both Roy and I. This is the thing though, I watched the first season on DVD on vacation, 2-3 episodes a day, it was riveting, no commercials, no waiting a week to see what happens. I watched a couple more seasons on DVD, but not at the same rate, and the plot started to get a bit confusing. Or rather there were too many different plots going on at the same time and more and more plot lines started with more questions being asked but not enough being answered. And I caught up to the real-life show, and now have to watch it on TV, with the week-long breaks between episodes, noise of regular life, and season breaks. The show travels back and forth through time, I never figured out why Benjamin (the bad guy) was shown for a flash as a security screener in the airport in Australia, or what was with the polar bear on the island, and now we travel back and forth in time in vague and mysterious ways. There are puffs of smoke, bodies lost and found, lovers in countries down the road, and an island that splits and has the magic power to heal cancer and paralysis Nothing quite rivals that first season, with the number sequence that had to be typed into the Dharma station machines ever 108 seconds or else...or else what?

So I'm Lost. It was good to read that other people are Lost, and that even the show's script writers have trouble keeping track of the intricate plot. I didn't realize there were over 100 characters. Will they be my Facebook friends?

And Therapy Patient, there had better not be 20 million people headed to Washington on Tuesday. Shrink Rap will be reporting.

Saturday, January 17, 2009

President-Elect Barack Obama is here speaking before he goes to Washington. I left my youngest person to stand in the cold and watch him (I'm warm at home, happy to watch on TV). I will be taking Tuesday off from shrink life to go to the inauguration in Washington. Crushing crowds, porta-potties, and a day filled with Hope.

If that's not enough, everything here is drenched in purple for the Ravens vs. Steelers AFC championship playoff game. I'm a fan by marriage, so sure, I'm Wacko for Flacco.

Thursday, January 15, 2009

There are things to do about symptomatic distress in addition to medications and therapy. I often encourage people to make themselves their own human experiments. There are a few things we can change easily: we alter our diets, sleep, exercise, and the assorted "substances" we ingest. I sometimes suggest to people that they do 2 week trials and see if something helps. Is your life better if you stop drinking for a couple of weeks, exercise mor or less, give up food additives, decrease the carbs in your diet, cut out or add caffeine? Pick a variable, change it for a time, and see if you feel better.

That being said, I've been having some trouble sleeping. I decided I'd take my own advice and change some things. Oh, but you know, I'm an impatient sort of soul, and I decided to change a few things all at once. They didn't seem like big things: I decided to cut out all alcohol and caffeine from my diet, to set the alarm for earlier in the morning and get up and exercise in the hopes of exhausting myself. I started on a Monday, not a day of the week I typically drink alcohol anyway, and also not a day I usually have time to exercise. And caffeine, well...a cup of java in the morning, maybe two, and a Diet Coke with dinner, maybe another during the day or maybe not. And I've gone months at a time without Diet Coke. I like it, but it's not the hardest thing to give up. Have I noticed that I feel better or sleep differently without soda? No. But this time, I'm giving up coffee, too.

5:45 AM, the alarm goes off, and 4 miles later, I begin my day, without coffee. No caffeine. No chocolate. No diet coke.6:15 AM Tuesday, and this is a day I normally exercise. Only I'm dragging, and it was an uninspired work out. By afternoon, I'm feeling really lousy. My head aches. I'm tired and fatigued, and I really can't sleep that night. It's the sleep deprivation, I think, getting up earlier than I usually do, after a night when I've had trouble falling asleep. Ugh.

By Wednesday morning, my head has ached for 2 days, and while I'm caffeine & nutrisweet free, I'm now downing Tylenol and Motrin but my head still hurts. It finally occurs to me that I'm in caffeine withdrawal. But I was never addicted! How can I be withdrawing? I look this up and realize this can last for up to 9 days. Suddenly it seems sort of ridiculous that I've changed multiple variables at once, and even worse that I've given up caffeine cold turkey.

The researchers identified five clusters of common withdrawal symptoms: headache; fatigue or drowsiness; dysphoric mood including depression and irritability; difficulty concentrating; and flu-like symptoms of nausea, vomiting and muscle pain or stiffness. In experimental studies, 50 percent of people experienced headache and 13 percent had clinically significant distress or functional impairment -- for example, severe headache and other symptoms incompatible with working. Typically, onset of symptoms occurred 12 to 24 hours after stopping caffeine, with peak intensity between one and two days, and for a duration of two to nine days. In general, the incidence or severity of symptoms increased with increases in daily dose, but abstinence from doses as low as 100 milligrams per day, or about one small cup of coffee, also produced symptoms.

Wednesday morning, I have a half a cup of coffee. Within a half hour, my headache is gone and my energy level is normal, I feel like myself again. I go for a swim and sit in the hot whirlpool for a while, ahhhhh.....

Wednesday, January 14, 2009

I want to begin by saying I don't have any insider info into the process and I don't have an opinion about what's going on. Which is good, because no one asks me.

The DSM is a book that lists the guidelines for making psychiatric diagnoses. It's like a Chinese Menu--- a few symptoms from column A, a few symptoms from Column B, and voila, you've got Diagnosis X. There have been 4 versions to date, and the 5th is in the works.

It would be nice if we could run a definitive test and say, Yup, the Depression Factor is present in your blood, you've got Major Depression, single episode, and the level is 75 so it's "moderate." Or look, the left side of the amygdala is enlarged, therefore it's Panic Disorder. Or, the frontal region has increased metabolism when you burp, so you've got Paranoid Schizophrenia.

It doesn't work that way, we don't have any definitive tests and when we do tests in psychiatry as part of a diagnostic evaluation. It's to make sure the patient doesn't have a brain tumor or a stroke or thyroid dysregulation or hypoglycemia or some other medical condition (that we can see or measure) that explains the symptoms. If the brain looks anatomically normal, if the blood is normal, if there are no funny substances that explain why someone is acting or feeling either badly or weirdly, then by default, it's a psychiatric problem. Some day this may change, but right now that's it. Researchers are making progress towards finding links between psychiatric illnesses (after they are diagnosed as such) and specific genetics or brain metabolic differences, but they don't make a diagnosis and it's all pretty new.

So how are diagnostic criteria decided? A bunch of people sit in a room and decide. They talk, they look at research findings, they pool their experience, and actually I'm not all that sure (keep reading, there are some answers below). The issue of diagnostic criteria and validity is laden with emotion-- there are people who like psychiatric labels, like the drug companies. And there are people who don't like labels -- like those who don't want their sexual preferences or gender distress labeled an illness, Health insurance companies pick and choose what diagnoses they will reimburse for. So once upon a time, homosexuality was a psychiatric illness and it's not anymore.

The DSM-V work groups are in place and these peeps are talking about the next volume and what should change. There have been issues with the process of what they are doing-- the members of these groups signed a non-disclosure document, and my email (why me?) gets messages from people complaining that the process is too secretive, and other messages stating that there is a need for some confidentiality during the process, but it's open and transparent. Today's email came from the American Psychiatric Association, pointing me to a Wall Street Journal blog post about the issue, so I will guide you to that: Click Here.

Oh, and while you're clicking, Roy also posted on this issue back in November: Click Here.Oh, and here's what the APA has to say about the how the process transpires:

The work groups began meeting in late 2007. While the 13 work groups reflect the diagnostic categories of psychiatric disorders in the previous edition DSM-IV, it is expected that those categories will evolve to better reflect new scientific understanding. With the understanding that some continuity from DSM-IV to DSM-V is desirable to maintain order in the practice of psychiatry and continuity in research studies, there has been no pre-set limitation on the nature and degree of change that work groups can recommend for DSM-V.

Each work group meets regularly, in person and on conference calls. They begin by reviewing DSM-IV’s strengths and problems, from which research questions and hypotheses are first developed and then investigated through literature reviews and analyses of existing data. They will also develop research plans, which can be further tested in DSM-V field trials involving direct data collection.In order to invite comments from the wider research, clinical, and consumer communities, the APA launched a DSM-V Prelude Web site in 2004, where these groups could submit questions, comments, and research findings to be distributed to the relevant work groups.

Based on this comprehensive review of scientific advancements, targeted research analyses, and clinical expertise, the work groups will develop draft DSM-V diagnostic criteria. A period of comment will follow, and the work groups will review submitted questions, comments, and concerns. The diagnostic criteria will be revised and the final draft of DSM-V will be submitted to the APA’s Council on Research, Assembly, and Board of Trustees for their review and approval. A release of the final, approved DSM-V is expected in May 2012.

After Dinah and I got trapped temporarily at Roy's place I had this sudden mental image of all three Shrink Rappers homebound together in a snowstorm: Dinah baking cookies, Roy tweaking the blog template and me climbing the walls.

It occurred to me that we have a diagnosis for people who have trouble leaving the house (agoraphobia) but we don't call it an illness if somebody goes crazy being at home for a long time.

I know people who always have to be on the go. After a day or two of hanging around the house, or sometimes a few hours, they have to get up and move around or at least take a walk. They're out shopping with friends or going out to lunch or otherwise on the move.

Me, I have learned the art of being a homebody. It was a necessary skill in my early days when a really good blizzard could strand you, doors drifted shut, for two or three days at a time. I'm convinced that upper Mid-Westerners became laid back and easy-going through natural selection---anyone who couldn't handle several days together in close quarters just killed each other off. Regardless, it's now an innate trait for some of us.

Some people describe themselves as homebound---the stay-at-home mom for example---but I know from my parent friends that stay-at-home moms are rarely at home. They're on the road constantly to and from doctor's appointments, school, sporting events and children's social activities. We also now have the 'stay-cation', people who spend their vacations at home because of the economic downtown. However, even stay-cationers aren't in the house the entire time. They're taking day trips or sightseeing local attractions they don't usually go to. They're just not going as far as they usually go.

We've even invented gender-based words for being a homebody: women "nest", men retreat to their "man-caves". (I cringe a bit at this, with the implication that for women to justify nesting they have to have kids, or that men need a place presumably to grunt, watch sports and scratch places they wouldn't scratch in public.) But there you have it, that's our culture, and mainly I was just amused when the pleasure of being at home became a fad. My innate instincts had become trendy.

The key to being happy at home is to first relieve yourself from the guilt of doing nothing. If you look around and all you see are the dust bunnies and a kitchen that needs to be renovated, that's a problem. If you can't rid your mind of all the errands---the dusting, the bills to be paid, the unpacked boxes leftover from your move several years ago---it's going to be hard to be comfortable in your nest.

Personally, all I need is a quilt, a good book and a place to curl up.

Tuesday, January 13, 2009

I watched the documentary Grizzly Man last night and it's still haunting me. It's the story of Timothy Treadwell, the failed actor and recovering alcoholic who dropped out of civilization and moved to the Alaskan wilderness to dedicate himself to the protection of grizzlies. The story became a documentary because, eventually, he and his girlfriend were killed by a grizzly. Their deaths were caught on audiotape, which mercifully was not played during the film.

There were so many things that fascinated and bothered me about this film.

On one level the documentatry represented a clash of cultures---the ecologically-minded friends who supported Treadwell's efforts to acclimate to the grizzlies versus the scientists and conserative traditionalists who felt this was dangerous for both the animals and humans. Given that the grizzly was killed by park rangers as they retrieved Treadwell's remains, fate eventually made the traditionalists' case.

The main character of the film was Treadwell himself---flamboyant and effeminate as he professes his love to every creature he encounters, yet adamantly straight when talking to his camera. Knowing that he aspired to be an actor made me constantly question whether or not I was seeing the real person during any given scene. Treadwell himself didn't seem to know his own reality. At one point he told friends he was an orphan from Australia and adopted an Australian accent as an affectation. Even his friend in California wasn't aware of this deception until after Treadwell's death. While living in the wilderness he recreated his persona again, this time as the center of his own story as he filmed over one hundred hours of himself and the bears. He became the lone martyr sacrificing himself for a higher cause, a form of rehabilitation through conversion to an ideal.

And then there is is ill-fated girlfriend, Amie Huguenard. LIttle is known about her because her family did not want to participate in the film. We are left to speculate about her reasons for following him into the wilderness and we could easily be wrong. She was afraid of the bears and considered leaving him, but stayed and died while trying to protect him from the bear attack. I'm left to wonder: was she a reluctant companion, a person naive to the wilderness who merely followed a charismatic eccentric? Was she a self-righteous rescuer who saw herself taming the wildman and, through love, bringing him back to civilization? We'll never know. We do know that in the end she was heroic.

What we do know about her and their deaths we find out through the creepy coroner who describes the attack, right down to the screams and moans. He describes their scanty remains and their wounds in vivid detail. It was awful to picture these unusual but vibrant people reduced to a small plastic bag inside a long metal box. I was struck by the questionable ethics of discussing this medical information, knowing that confidentiality (in theory) is supposed to extend beyond the death of the patient. If Amie Huguenard's family did not want to participate in the documentary it's questionable that they would have given permission for the pathologist to discuss her remains.

In the end Grizzly Man is not a story about bears. But it's still a story worth telling.

Monday, January 12, 2009

So Clink and I went to see Roy today. He has a big big screen and if you want to do work as a group, it's really helpful. We wanted to review our Table of Contents for our book proposal, to make sure we covered what we want to cover, to make sure we weren't being repetitive. This is an interesting process just writing a proposal with three people. Roy suggested we might need three keyboards and three mice to control the single huge screen. I suggested that if we did that, we'd also need a gun. Things get a little loud. I'm the least detail oriented of the three of us, and I tend to type fast but not quite as fast as I think, so often my stuff is missing a word here or there. What's the biggy? Roy likes the to be perfectly consistent and he worries over every word. Clink, well, she's more of a big picture type of nun, so she sits there in her habit and only gets bloody once in a while.

So Roy is in a hurry, busy man with obligations to be met. Suddenly, he's handing me a key and telling me we can stay as long as we like, but do lock up. He's off. Clink and I remain, clicking away at our document, and at the end, I'm left with Roy's 75 open documents on the screen, layered and overlapping, and never fully closeable, simply trying to log out of my own e-mail account because I don't want a whole gang of people later having a party over the ridiculousness of what goes on in my life.

We're finally done and Clink and I gather up our junk. Bye to doggy. Out we go. Oh, but we can't get out. There are Two locks on the door and we're twisting and turning for a while. Finally Clink says, "When did he say he's coming back?" Uh, he didn't. We try the top lock and then the bottom lock and some random pulls here. I got stuffs to do. Clink says "This is definitely a blog post." This makes it better. Clink always makes it better. I laugh at the thought, and we're both about to turn back to the mega-screen to start blogging away about being trapped and Royless at Roy's, when the last turn of the lock and pull on the door finally frees us.

Sunday, January 11, 2009

In "Down and Out-- or Up" New York Times write Benedict Carey (he likes to write about psych stuff) discusses suicide, psychological distress, and resilience in the face of the crashing economy. Carey writes:----- Just as loss itself comes in different flavors, from the bittersweetness of divorce to the acid tang of public condemnation, so too do people’s responses to loss differ, sometimes wildly. There are people who fall hard and do not find their feet for a long time, if ever — a condition some psychiatrists call complicated grief. And the depth of this economic collapse has unceremoniously stripped thousands of far more than money: reputations have reversed; friendships have turned sour; families have fractured.------I agree-- some people grieve and move on quickly, others never go back to who they once were (even with therapy and anti-depressants). I wouldn't have put it, though, that they do not find their feet, I would have said they find different feet. They become a little of someone else, often someone who isn't quite so motivated to work or travel or run in the rat race as the person they were before, but someone who might eventually find a new and quieter life. It is as if their values and goals change. Sometimes, it seems, that's just the way it is.

Carey goes on to write:

--- In any group of people, moreover, there will be a handful who are exceptional, who find some release or hidden opportunity in a seemingly devastating loss — a kind of Zorba response. In one study in England, psychologists found a bricklayer who, after being paralyzed, became an academic and now says the injury was the best thing that ever happened to him. Other research has recorded significant improvements in the lives of some people after they lose a loved one.---I'll end with that. Oh, but in case you missed it, the Ravens won.

Saturday, January 10, 2009

I'm so glad ClinkShrink lived through jury duty....she was sending out 'bored and starved' distress messages.

So Novalis comments on our posts sometimes and I've visited his blog: Ars Psychiatrica. I wanted to add it to our blogroll, but once Roy has been somewhere, it's usually pretty complicated and I wasn't sure I could add something without blowing Shrink Rap to bits.

Now Novalis has visited and commented at times. In my head, he's been a "she." Why? I don't know, but I had this image of a female psychiatrist. Maybe it's the long hair in his profile pic. It wasn't until I started reading his blog that I suddenly felt some need to know: What gender? I went to his profile view, and discovered a fair amount about him-- first off that he's a HE and that he's a community psychiatrist (I like them). The North Carolina part didn't surprise me.

Sometimes our readers tell us about themselves-- their careers, their reason for an interest in mental health, where they're from, and maybe their names or their photos give away their gender (hi to Zoe Brain across the globe whose blog tells of his he-to-she journey)...sometimes I can glean their age, sometimes people just tell us or put it on their profiles. A few we've met: TigerMom and Sophizo met us at a conference.

Is there something about the mystery of it? Someone wrote a guess about us in our comment section recently: I was described as a cookie-baking mom with glasses and my hair in a bun. I bake cookies a couple of times a year, wear contacts, not glasses, and have never once, not even for a single hour, worn my hair in a bun.d

Friday, January 09, 2009

So here I am, juror number 206, sitting in the juror assembly room. I have not been called for a case but I am patiently waiting, having read the New York magazine from cover to cover and learned all about the best new restaurants of 2009, the new Mamet play and the latest exhibit opening at MOMA.

It's been a pleasant---or at least not odious---experience so far. The parking was plentiful, free and easy to locate. The chairs are comfy, the court house is within walking distance of several decent restaurants and I even have free WIFI. It's kind of like a better version of an airport terminal, without the screaming babies. (Oh yeah, and no mildew.)

After checking in, the morning started with an orientation video that reminded me of those black and white Bell Lab films they used to show us when I was in high school. It did a good job of explaining who works in the court room, the trial process and the job of the jury. I'd like to get a copy of it for my beginning forensic students. It ended with the chief judge telling us that he hoped our jury experience would be "educational and rewarding". Then they turned on the movie, title forgotten, starring big name actors in a G-rated film I had no interest in watching. They told us if we didn't want to watch the movie we could go to the designated 'quiet area' in the snack room, so here I am. The young dude slacker sitting at the table next to me doesn't get the concept of a 'quiet area'. I really didn't need to hear the story about him seeing an alligator eat a dog.

It feels a little weird knowing that I've spent more time in front of a jury than in a jury box.

It's a little weird knowing that any of the ninety criminal trials scheduled today could involve one of my former, current or future patients. In my jury qualification form I clearly documented that I work in a prison, that I evaluate criminals, that I'm greatly needed and would be missed if called away for several days. I'm hoping somebody reads this.

Obviously, if I actually get empanelled I won't be blogging about the experience or talking about the case. Also obviously, if one of my patients shows up at the defendant's table I'll let somebody know I can't serve. I just hope he doesn't holler out in the court room, "Doc, I really need my medicine upped!"

Thursday, January 08, 2009

So my kid comes home from school today and announces,"Guess what I learned at school today?""What?" (Good to know they're learning something, anything....)"There are a lot less kids at my new school with ADD then there were at my old school.""Oh? How do you know this?" Shrink Mom's wondering if they do public surveys or something."I wrote with a Concerta pen all day and no one came up to me and said they were taking it. Tomorrow I'm going to try a Prozac pen."

Hmmmm.......

So the scientist in me thinks of all the options here:1) Kids at old school were more open about revealing their psych histories2) Difference between middle and high school?3) Kids at current school less attentive to classmates' choice of pens?4) More kids at old school actually did take Concerta.

I do recall that in the past, when my kids have taken pharmaceutical company pens to school, they've gotten personal as well as family histories offered ("Hey, my dad takes that!").

I'm not sure what makes these suicides more newsworthy than the death of one of my neighbors a couple years ago that didn't make the newspaper, or the hundreds of other suicide deaths that happen every month in this country, but there it is on CNN. Maybe it's a media comment on the state of the economy. Maybe it's the shock value of a successful or wealthy person just throwing it all away and giving up. Maybe it's a morality tale that materialism doesn't lead to happiness. Regardless, the stories draw eyeballs just for the schadenfreude of watching someone fall from a high place.

In our local newspaper there were stories about other recent suicides: a Pennsylvania politician who was also an accused serial rapist and a school teacher who was accused of assaulting a student. The New York Times recently had an in-depth story about the Fort Meade scientist who committed suicide under the stress of the FBI anthrax investigation. These are deaths at the other end of the social spectrum, involving people who might generate a lot less sympathy than the businessmen. In other situations like this I've heard people suggest that the accused 'had it coming' or even express relief that money wouldn't be wasted on a trial.

Does it really matter? The impact of suicide on the spouses, family, co-workers, friends and neighbors doesn't depend on the deceased's social status. And I cringe at the implication that perhaps suicide prevention may not be quite as crucial for people who are less deserving than others.

A pedophile patient of mine thought it was important that I believe he was innocent, as if I'd give him worse care because of his offense. I finally shocked him by telling him, "It doesn't matter if you did it or didn't do it, you still deserve to be healthy."

Tuesday, January 06, 2009

One of our readers asked me to comment on how psychiatrists who work in corrections keep from becoming 'hardened' to their patients when so many of them are 'lying jerks' (anonymous reader's words, not mine).

The question was weirdly relevant this week.

I came back from a week off to find that our entire department was flooded. A three inch pipe (clean water, fortunately) broke over the weekend and left a five inch layer of water over our entire floor. It leaked from the third floor tier all the way through to the first floor entrance. I don't even want to think about how many gallons that was.

The water had been vacuumed by the time I came in but the smell hit me immediately. There are no words to describe this. Employees came in, took a sniff, and immediately turned around to leave. I had no idea carpets and paper could mildew so fast.

So back to Anonymous's question: How do you keep from becoming hardened?

The short answer is: It's demoralization you have to watch out for, not insensitivity.

Psychiatrists become psychiatrists because they like their patients, and generally I do. Every psychiatrist has an occasional patient who conceals information, is deceptive or sometimes unpleasant. This goes with the territory and isn't limited to forensic work. It's part of being human and most human beings don't reveal everything about themselves immediately, or at least not the unseemly bits. I don't take patient deception personally. It's part of the job. It's possible to lose one's naivety without becoming jaded or cynical.

The real challenge can be to keep up your morale (or at least not undermine your co-workers' morale) in the face of repeated broken pipes and flooded offices, uncontrolled air conditioning (or no heat), disappearing resources and quality assurance administrators who believe a new form is the answer to every problem. Demoralization is the death by a thousand cuts, more subtle and deadly than any nasty cursing sociopath.

My advice to the 'new fish' in the field is to be careful who you associate with and listen to. It may be nice to have a co-worker to vent to, but if all the two of you are doing is venting then there's a problem. Disgruntlement is contagious and the more you listen the more it feeds. Find the cheerful co-worker (there always is one, the polly anna who sees a broken pipe as a chance to clean out the office) and hang out with that person once in a while. Take a break and spend some time planning your next vacation. Hug someone you care about. Kiss your dog. If I were Dinah, I'd eat a hot fudge sundae. (Oh wait, I do that anyway.) Know that this aggravation, too, will pass. Then aggravation will happen again. Then pass. Then...well...you get it. Eventually you, the new fish, will be advising others how not to become 'hardened'.

Monday, January 05, 2009

Here are the Top Ten most viewed posts which were written in 2008. (I'll do a Top Ten ever if folks want it, but this gets skewed because being in the top 10 for 2007 results in even more hits, so it becomes circular.)

"And what do we mean when we say that someone "could" change if they only "would?" In some alternative universe? If they were us? It may be more reasonable to think that someone can change when they, in fact, do change, and not before then. In that sense we only know reality after the fact."

So, in yet another NY Times piece:Modern Love Facing My Obsession, in the Flesh By BENOIT DENIZET-LEWISPublished: January 2, 2009, Denizet-Lewis writes in a poignant way about his struggles to resist sexual impulses to connect with strangers:---------------But pride is no match for addiction. This morning I’d resolved to break my habit, to make the day different. I knew I needed to get some work done before heading to a childhood friend’s wedding later in the day. No time for sex! But as I sat at my desk, a thought occurred: “If I am not going to have sex today, I should take care of business now.” I decided to look at pornography online for 15 minutes (20 minutes max). An hour into that, I got an e-mail message from Mike saying he wanted to meet. I decided to skip the wedding.----------------------Denizet-Louis goes on to write:----------------------As I sped home, I wanted to cry. What was happening to me? Why couldn’t I stop chasing sex, no matter the consequences? To make myself feel better, I called Mike. He answered, offered a convoluted excuse involving flat tires and dead cellphone batteries, and then we had phone sex. When we were done, I considered driving my car off a cliff.TO much of the general public, sex addiction is a punch line, a pop-psychology diagnosis or an attempt to explain away recklessness and perversion. But my sex addiction is unfortunately very real; it has cost me a job, romantic relationships, friendships and, on many days, my sanity and self-respect. I have checked myself into inpatient sex-addiction treatment centers twice. I have set up Internet blocking software — the kind designed for children — on my computer, only to buy another computer when the urge to go into chat rooms became too strong. -------------Sometimes it seems easy enough to say "if you don't like your life, change it." Sometimes it's hard to appreciate just how difficult that can be.

Sunday, January 04, 2009

In "Creature Comforts" (the NYTimes mag, of course), Rebecca Skloot discusses all forms of comfort and service animals. There's a difference, and yup, Ducks make the cut. There are miniature guide horses for the blind, monkeys for quadriplegics, and an assistance parrot for a man with bipolar disorder who is subject to tempter outbursts.----------What qualifies as a service animal? .... Can any species be eligible?

There are two categories of animals that help people. “Therapy animals” (also known as “comfort animals”) have been used for decades in hospitals and homes for the elderly or disabled. Their job is essentially to be themselves — to let humans pet and play with them, which calms people, lowers their blood pressure and makes them feel better. There are also therapy horses, which people ride to help with balance and muscle building.

These animals are valuable, but they have no special legal rights because they aren’t considered service animals, the second category, which the A.D.A. defines as “any guide dog, signal dog or other animal individually trained to do work or perform tasks for the benefit of an individual with a disability, including, but not limited to, guiding individuals with impaired vision, alerting individuals with impaired hearing to intruders or sounds, providing minimal protection or rescue work, pulling a wheelchair or fetching dropped items.”

Since the 1920s, when guide dogs first started working with blind World War I veterans, service animals have been trained to do everything from helping people balance on stairs to opening doors to calling 911. In the early ’80s, small capuchin monkeys started helping quadriplegics with basic day-to-day functions like eating and drinking, and there was no question about whether­ they counted as service animals. Things got more complicated in the ’90s, when “psychiatric service animals” started fetching pills and water, alerting owners to panic attacks and helping autistic children socialize.-----

The article includes issues about disease transmission, especially forms of hepatitis from monkeys, to issues of aggression, citing one service dog who killed another service dog on a bus. People, apparently, are not always comfortable seeing duckswalking down grocery store aisles (can someone explain that to me?)

The article concludes with:

--------------------

“Many people try to make this issue black and white — this service animal is good; that one is bad — but that’s not possible, because disability extends through an enormous realm of human behavior and anatomy and human condition,” Frieden told me. In the end, according to him, the important thing to remember is this: “The public used to be put off by the very sight of a person with a disability. That state of mind delayed productivity and caused irreparable harm to many people for decades. We’ve now said, by law, that regardless of their disability, people must have equal opportunity, and we can’t discriminate. In order to seek the opportunities and benefits they have as citizens, if a person needs a cane, they should be able to use one. If they need a wheelchair, a dog, a miniature horse or any other device or animal, society has to accept that, because those things are, in fact, part of that person.”

Friday, January 02, 2009

My farewell post to 2008 was a bit gloomy. If that wasn't enough, I came upon this article in the New York Times by Alex Williams: New Year. New You? Nice Try.

It starts with Oprah's re-gained weight (please, everyone, leave poor Oprah alone...she's great at all weights). Nail biters, drinkers, dieters, even those with heart disease trying for healthier diets don't make much progress in Williams' article:“Most of us think that we can change our lives if we just summon the willpower and try even harder this time around,” said Alan Deutschman, the former executive director of Unboundary, a firm that counsels corporations on how to navigate change, and the author of “Change or Die,” a book that asserts that even though most people have the ability to change, they rarely do. “It’s exceptionally hard to make life changes,” Mr. Deutschman said, “and our efforts are usually doomed to failure when we try to do it on our own.”

There are cases cited of someone who vows to learn to cook, and someone who wants to get a drivers' license.

Is it really all that hopeless? Ranting without data, I don't think so. Weight change is hard-- it's a battle against biology. But in the course of talking with patient about their history, it's not so unusual to hear that someone quit smoking or drinking many years ago, or made a change only after years of deliberation. The woman Williams talks about who vows year after year to learn to cook but still subsists on Honey Bunches of Oats--- my guess is she either likes the cereal better or she doesn't really want to learn to cook. Please forgive me this once for discussing the motivations of someone I've never met, but this was hard to resist, especially given my own preference for Honey Nut Cheerios.

Are our efforts to change really "doomed to failure when we try to do it on our own" as Deutschman, quoted above, suggests? I think it's a skewed population: if you vow to change and do, you don't seek help. You don't enter a study. You just make a change.

Thursday, January 01, 2009

It's over. It's over. Can I tell you how glad I am it's over? Did anyone have a good year? Michael Phelps seems to have managed okay. And somehow I think Barack Obama enjoyed 2008 more than he will enjoy 2009.

The rest of it: it can be done with.

We saw the worst stock market decline in 77 years with the S&P 500 down about 40 percent. Banks failed, housing prices failed; who's next in line for a bailout? Lehman Brothers liquidated, Merrill Lynch sold out, the list goes on.We're still fighting a war in Iraq, and Afghanistan. Terror in Mumbai, continued unrest in India and Pakistan, the war between Georgia and Russia, nuclear power in Iran, and Hamas and Israel continue to fire on Israel with no signs of peace.An earthquake in China, floods in the midwest, I lost count of the hurricanes-- Ike and Gustav, to name a couple. Wildfires in California.We've learned that a single man can steal tens of billions of dollars over the course of decades without being detected. And a governor can try to sell a senate seat. Trust-- what's that?I've ignored whole continents here--